Painkiller Misuse in Football Part of the Job?

FEATURE / DANIEL READ, AARON C.T. SMITH & JAMES L. SKINNER

Introduction

If boxing is the ‘hurt game’ then professional football has surely become the ‘pain game’. Individualism and a competitiveness are deeply embedded within professional football and while these values make for dramatic sport experiences, it also means that players are treated as commodities that can be retired and discarded once their physical capabilities are exhausted. In order to remain employable for as long as possible, professional footballers endure significant physical trauma that leaves them bruised, battered, and vulnerable to varying levels of post-game, and ultimately, post-career, stress.

Of course, some commentators might argue that at least a small percentage of professional footballers are exceptionally well rewarded for their pain and that the former description of big-time sport is alarmist and exaggerated. However, our research exposes the ways in which painkilling drugs can be seen as tools that sport managers, coaches, scientists, and players use to maximise game time and longevity. So, while the presumption that players should be able to manage their bodies in ways that are consistent with their own beliefs about the practice and performance of sport, we have confronted the disconcerting possibility that players need protection from imposed drug misadventures and misjudgements.

Painkiller Misuse in Football

In recent years, numerous high-profile retired footballers have admitted to painkiller misuse during their careers that led to long-term harm (Read et al., 2022). The therapeutic use of analgesic substances and injections is common practice in football to enable players to compete through minor injuries, however, sport physicians have raised concerns about painkiller (mis)use without medical need and/or supervision in football (Correctiv, 2020; Tscholl & Dvorak, 2012). Our research aimed to understand the motivations for painkiller misuse from a relational perspective by considering the interaction between player experiences and their working environments. In exposing the pressures footballers are under to use painkilling drugs, we have been able to identify a set of risk factors sports medicine practitioners can employ to locate and assist players vulnerable to misuse in order to reduce harm and prevent long-term damage. Sport clubs, no matter the performance level, like to see their athletes available for selection as soon as possible after injury, meaning overthe-counter painkillers are widely used to relieve discomfort and enable increased range of movement. Additionally, painkilling drugs may offer temporary performance enhancement although effects vary by substance (Holgado et al., 2018). As a result, perhaps unsurprisingly, painkiller misuse is common across endurance, collision, and combat sports (Harle et al., 2018) with these athletes reporting higher levels of painkiller use relative to the general population (Alaranta et al., 2006).

To complicate matters, given the clandestine nature of painkiller misuse, limited data are available specifying the extent of the problem in football. Reports from Germany have highlighted that both professional (Trinks et al., 2021) and amateur footballers (Correctiv, 2020) are engaging in prophylactic painkiller use without medical need. Likewise, medication reports provided by team doctors covering the 72 hours before kick-off at World Cup matches indicated that painkiller use is common at the highest level of the game (Oester et al., 2019). Figure 1 shows that of the 736 players from 32

countries present at the 2018 World Cup, approximately 2 in 5 used a non-steroidal anti-inflammatory drug (NSAID) at some point and approximately 1 in 5 used an analgesic. Anecdotal stories of painkiller misuse are also plentiful with players reporting habitual painkiller consumption contravening medical guidance as part of a psychological routine or to deal with long-term pain from injuries or surgery (Read et al., 2022). Although the lack of data makes it hard to ascertain the true scale of the issue, recent research including ours suggest that misuse is more common than publicly acknowledged.

The misuse of painkillers is worsened by the fact that most analgesic substances are not banned by the World Anti-Doping Agency and are available from team medical staff. Additionally, paracetamol and NSAIDs are readily accessible from pharmacies without a prescription in most countries. The combination of legality and availability has led to a perception among athletes that painkilling drugs are safe in comparison to prohibited substances (Fincoeur et al., 2020). In reality, extended misuse of painkillers can lead to gastrointestinal damage, renal and hepatic failure, cardiovascular problems, addiction, and long-term musculoskeletal conditions (Warden, 2009). We do note that legitimate therapeutic painkiller use under proper medical supervision to enable players to compete through minor injuries also presents risks, such as injury exacerbation, but medical practitioners are more readily able to monitor players and prevent harm.

Research in other sports has pointed to a variety of precursors leading to painkiller misuse, including performance enhancement, loyalty to teammates, and avoiding being labelled as ‘weak’ or ‘soft’. Notably there is a dearth of studies focusing on pain, injury, and working conditions as drivers of painkiller use and misuse in football (Roderick, 2006; Roderick et al., 2000; Roderick & Schumacker, 2017). Our research therefore began by assuming that identifying the pressures professional footballers face contributing to the decision to use painkillers, would help reveal how they might be best safeguarded from harm. Our approach was to look at the problem from the position that football players have a finite period through a professional career in which to convert their footballing and bodily ability into economic rewards. As a result we found that professional players are forced to make a trade-off; their physical health in exchange for economic prosperity, or more specifically, physical capital for economic capital (Bourdieu, 1986).

Physical capital and player working conditions?

Our review of studies into the experiences of professional football players alongside the analyses of interviews with players who admitted to prophylactic misuse identified a working environment characterised by (1) risk of injury (2) employment vulnerability, (3) lack of alternate employment opportunities, and (4) reward for loyalty and toughness. Each of these four elements aggregated to cultivate a workplace encouraging the systematic use of painkilling drugs. First, the career of a professional footballer will inevitably be challenged by injury and a player can typically expect 2 injuries per season of varying severity (Ekstrand et al., 2011). Player welfare remains a hot topic in football medicine, and the increasing physical intensity of matches and congested playing schedules remain a point of contention as players are expected to compete in an ever-escalating number of games. With intensified playing schedules and workloads comes an inevitable increase in the risk of injury (Bengtsson et al., 2013). Against the backdrop of a limited window for commercial gain, injuries are a threat to a player’s relatively brief economic window of activity.

Second, most footballers face employment vulnerability and risk of replacement. For instance, in 2018, the longest average contract given to players across Europe’s big five leagues was 3.23 years, (FC Barcelona) whilst the shortest average contract length was 0.99 years (Amiens SC) (Poli et al., 2018). Relatively short-term employment guarantees are compounded by the sheer volume of competition for a limited number of work opportunities and the constant supply of new talent through academies and scouting. Again, prophylactic painkiller misuse mitigates against potential lost playing time and offers psychological boosts to showcase a player’s talent in pursuit of further employment at the end of a contract. Third, in pursuit of a professional career, most footballers sacrifice other areas of personal development, such as the attainment of formal educational qualifications (Adams & Darby, 2020; Agergaard & Sørensen, 2009; McGillivray et al., 2005). Players find themselves in a position of dependence upon their footballing career given the uncertainty that often accompanies retirement due to a lack of perceived opportunities. Therefore, players are dependent upon maximising the economic rewards available through their limited career spans.

Fourth, professional football culture rewards loyalty to teammates and toughness (Roderick, 2006; Roderick et al., 2000). Players who are frequently injured, unwilling to play through injury, or simply fatigued, are considered a liability (Cunningham, 2018). Such working conditions are conducive to painkiller misuse to meet powerful cultural expectations.

The working environment of professional football is highly conducive to painkiller misuse as most footballers outside the cadre of players able to retire on their career earnings are faced with a dwindling time window to convert footballing ability into economic reward. The short career span is exacerbated by injury, short-term contracts, employment dependency, and a masculine culture towards pain. Based on these working conditions, risk factors for misuse can be identified and used to assign risk scores.

1. Players approaching the end of their contract. 2. Players approaching the end of their career. 3. Players with a high training and match workload. 4. Players recovering from recent surgery using painkillers. 5. Players with a history of severe injury. 6. Players who have an image of being tough. 7. Players with few vocational or educational qualifications. 8. Fringe players with unstable positions in the team.

Harm Reduction and Closing remarks The problem of dealing with painkiller use is bound up in the culture and context of contemporary sport. Given sport’s hypercompetitive and hyper-commercial values, it is impossible to envisage a professional footballing world without painkilling drugs. At the same time, it is hard to deny the need for some form of regulation to protect sport and its various stakeholders from the organisational and human costs that arise from uncontrolled substance use. One option is a harm reduction policy that allows athletes to manage their usage in a safe and secure environment. While a harm reduction policy is controversial in sporting circles, it accepts that drugs will always be part of the sporting landscape and aims to minimise the harm associated with their use.

Given the stakes at risk for professional footballers, it seems sensible that a harm reduction attitude towards painkiller misuse is considered rather than a strict abstinence approach seen in other substance use policies. The nature of a professional sports career means that a footballer’s physical readiness will often be in a grey area influenced by fatigue, previous injury, and psychological attitude and practitioners

face a difficult decision in determining whether to prescribe analgesics. Therefore, open honest dialogue with players about risk and rewards and safe usage should be privileged.

It is beyond the remit of sports physicians to resolve the work pressures players are subject to, however, practitioners are well positioned to reduce the potential damage footballers may inflict upon themselves. Practitioners are therefore advised to:

1. Identify individuals who may be susceptible to painkiller misuse. 2. Research attitudes and behaviours towards unsupervised prophylactic painkiller use within the squad. 3. Work holistically with performance staff to reduce workload where possible. 4. Educate players about safer practices, addiction, and alternative substances and methods to lessen risks. 5. Highlight post-career player development initiatives and engage with exit health examinations.

We conclude that prophylactic painkiller misuse is better understood as a result of working context and experience rather than of individual deviance. Professional football players who take painkilling drugs are not exceptions, cheaters, or addicts, but rather are caught between the unwelcome options of playing and making a living using painkilling drugs, or of being discarded and jobless but without the deleterious health effects of painkilling drugs. Unfortunately, as we discovered, the two are not always mutually exclusive because the former group are ultimately forced to retire and many do so with the damage already done, and with a lifetime of drug use ahead of them to live without pain.

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